Coordinate and plan interdisciplinary care
Serve as liaison to physicians
Facilitate Quality Improvement and dissemination of best practices
Mentor and coach less experienced nurses
Communicate with patient/family

Transcript

My name is Judi Consalvo. I’m a program analyst in AHRQ’s Center for Outcomes and Evidence. We are very excited about today’s topic and glad to see that you share our enthusiasm. We will be polling you in a few minutes to get a better feel for who has joined us today.

We also welcome your thoughts on other topics we could address with you. At the end of today’s event, your computer will automatically take you to a brief evaluation form. Please be sure to complete the form, as your comments will help us to plan future events that meet your needs. You can also e-mail your comments and ideas to us at info@innovations.ahrq.gov. (READ: info-“at”-innovations-“dot”-ahrq-“dot”-gov)

Karen George: Karen is more of an educator serving in CNL role, Misty with me is attending CNL program.

Katie Siegrist:I am the recruiter for Montana State University’s CNL graduate program option.

Host Judi Consalvo: We proudly present this Chat because we appreciate the importance of nursing innovations, including innovations that take place in the very challenging care setting of hospitals.

I’d like to introduce our moderator for today’s event: Marilyn Chow. Marilyn is the Vice President of Patient Care Services in the Program Office at Kaiser Permanente. She is also the Program Director for the RWJ Executive Nurse Fellows Program. Dr. Chow has made significant contributions to nursing throughout her scholarship, leadership, and political and civic involvement.

Linda Leavell: I work in a national role for an organization in patient care services.

Host Judi Consalvo: I would also like to introduce our team of innovators. Innovations are almost always a team effort, and the new role of Clinical Nurse Leader at St. Lucie Medical Center in Port St. Lucie, Florida, is no exception. Nancy Hilton is the Chief Nursing Officer at St. Lucie Medical Center, 194-bed hospital. She has been CNO at St. Lucie for 14 years.

Julie Shinn: Dr. Chow, Could you share the extent of or plans for implementation in the Kaiser system?

Host Judi Consalvo: We will also be chatting with St. Lucie’s team of Clinical Nurse Leaders. They include Lori Smith, Clinical Care Coordinator; Barbara Edwards, Karen Giovengo, Evelyn Rudd, and Gina Shouse

Panelist Evelyn Rudd: @Robyn Welcome

Kim Hall: CNL in a Geriatric Evaluation and Management Outpatient Clinic in South Texas Veterans Hospital

Kari Hamson Kalis: I am certified CNL and our hospital is going to pilot CNL model starting in May

Kathy Swarthout: I am a student in a MSN program, looking forward to teaching RN students.

Panelist Nancy Hilton: we needed clinical expertise at the bedside

Panelist Barbara Edwards: @Carolyn Cagle — I think we met some CNL students from TCU in San Diego

Kari Hamson Kalis: to bring organizational goals/outcomes to the bedside

Panelist: Barbara Edwards: @Kari Kalis — We have 4 certified CNL’s and two more in school. We have been succesful in implementing the role on our inpatient units.

Margaret Baird: How does one initiate the CNL role in a small rural hospital?

Panelist Nancy Hilton: we needed continuity across the continuum

Glenda Webb: I have just started a new position as Staff development.

Frances Seevers: two brand new certified CNL’S As of 2pm today here in ohio,… looking for jobs in our area

Kim Hall: A clinical leader to bring EBP to the bedside

Bonnie Denholm: I am confused about the CNL role and was hoping to get clarification here today

carolyn cagle: Thanks Barbara — about the connection to TCU

Barbara Edwards: @Frances Seevers — AWESOME

Virginia Hostetter: Approximately now many CNL are needed per bed size? We are not a large academic facility only 162 beds

Kari Hamson Kalis: Hi Barb, We are truly beginning and really trying to work out the details as much as possible before go-live in May

David Hughes: What are your thoughts about how the CNL fits into the hierarcyhy of the typical acute care hospital? Are they peers with the ANPs and the CNS’s?

Peggy Barksdale: CNL is not a CNS

Kathy Swarthout: CNL sounds like what the BSN was supposed to be

Karen George: I’ve worked with CNSs and am currently working with a CNL—2 great specialties with unique assets to the healthcare arena

Nancy Hilton: @Virginia…we have a CNL for every 18 patients. some hospitals are able to do a lower ratio

Peggy Barksdale: So is the CNL collaborating with your facility’s CNS Karen?

Panelist Barbara Edwards: @Kari — We began talking with staff and leadership months prior to implementation. We had some formal dialogue sessions as well as informal “breakroom” discussions. We tried to prepare the staff as much as possible.

Frances Seevers: thank you… check out website for American Association Colleges of Nursing.. has a nice chart compares CNS to CNL role

Karen George: I’ve seen the CNS role as clinical experts unit based with system applications. CNL as a more general role

Vivien Cruz: How do you avoid utilizing the CNL as a staff during a short staff crunch?

Panelist Gina Shouse: @Kathy a CNL is an advanced generalist and master’s prepared nures, a clinical expert at the bedside

Nancy Hilton: @David Hughes…the CNL reports to the nursing director/manager or that particular nursing unit. The CNL is the clinical quality expert

Panelist Evelyn Rudd: @Kari A Clinical Nurse Leader we provide lead with Interdisciplinary Rounds, bring EBP to the bedside, work with New Employees, & graduate Nurses, We are the link for communication between families, patients, & healthcare staff

Panelist Nancy Hilton: @Brenda Cook…you have to find a partner university that has a CNL program…more of them are starting the program

Panelist Barbara Edwards: @Vivian — How do you avoid using your managers when you have a staffing crunch? It is a different role and cannot be used to replace one from the other. There may be times when you have to change priorities but n ot roles.

Panelist Nancy Hilton: @Michele G.…that is great you are working in the ED as a CNL. thanks for pioneering in the ED. We have not implemented in the ED yet!!

Kathy Swarthout: Are CNL’s shifted from one area to another to fill staffing shortages?

Kim Hall: All nurses are expected to bring EBP to the bedside, however a CNL studies at the microsystem level (unit level) and can assess the patient population and synthesize processes, patterns, as well as the needs of professionals to deliver the resources and care for the patient

Panelist Karen Giovengo: @Virginia St Lucie is 224 bed hospital with 4 CNL’s and 2 more in school

Panelist Barbara Edwards: @Lisa Guy —CNL’s assist the bedside nurse in understanding EBP and assisting them in implementation. It is hard for some nurses to change their practice the CNL understands the difficulties in delivering patient care

Peggy Barksdale: Evelyn how many patients from admit to D/C does the CNL handle day wise, week, etc…?

Panelist Nancy Hilton: @Tena…yes CNLs can function throughout the hospital. Most CNLs are in acute care at this time, but there are also CNLs in the school system

Panelist Nancy Hilton: the CNL program on a part time basis is 2 years ie 33 credits

Panelist Gina Shouse: @Kathy — yes. A CNL is a clinical expert at the bedside, mentoring and coaching the bedside nurse

Karen Carnes: Is there a role for CNLs outside of the acute setting?

Bonnie Denholm: how is CNL different than a case manager or CNS?

Panelist Evelyn Rudd: @Peggy depends on the unit census between 18-22

Nancy Hilton: @Katherine…strong focus on research and EBP to be a CNL with a quality focus

Kari Hamson Kalis: would love to connect with a 12-16 bed unit who has implemented and look at your implementation process and current workflow — would like to do a telephone conference with an organization regarding this. If willing to help or collaborate, please email kmhamson@gundluth.org (Kari Hamson-Kalis RN, MSN, CNL)

Virginia Hostetter: Does St. Lucie have a Quality Department? And What is Quality Dept. role in relation to the CNL approach?

Kari Hamson Kalis: would love to connect with a 12-16 bed unit who has implemented and look at your implementation process and current workflow — would like to do a telephone conference with an organization regarding this. If willing to help or collaborate, please email kmhamson@gundluth.org (Kari Hamson-Kalis RN, MSN, CNL)

Peggy Barksdale: See, 2 years — 33 credits — how does the CNL become an instant “expert” clinically?

Margaret Baird: Any VA folks online? Wondering if you guys have implemented the CNL? Do you detect any differences in the VA system versus the Community Hospitals in your area?

Peggy Barksdale: Evelyn thank you for the answer

Panelist Barbara Edwards: @Bonnie — A Case manager focuses on discharge planning and discharge needs. A CNS focus on a specialty area. The CNL is an advanced generalist — they focus on a cohort of patients — from admission through discharge.

Eron Wahid: I work as a patient care facilitator at the VA in houston which is a modified CNL role.

Panelist Barbara Edwards: @Peggy — I don’t know that a CNL becomes an expert “instantly.” Through education and practice they bring a strong knowledge of nursing to the bedside. They are Master’s prepared — this education includes a component of assessment and pharmacology from the ARNP tract.

Panelist Nancy Hilton: @Lisa…I understand the question…several of our CNLs used to be charge nurses. The focus on the generalist masters program provides a broad spectrum…huge focus on research and EBP. They work across the system with many depths including case management

Panelist Evelyn Rudd: @Eron, we have heard of the position in the past, other facilities refer to it as patient care facilitator

Panelist Nancy Hilton: We have moved beyond the 2 pilot units. We have added it to our Med/Oncology unit and next will be our Ortho unit

Panelist Evelyn Rudd: @Eron, We also participate with the NDNQI

Peggy Barksdale: @ Alice —I liked your collaboration CNSs do work in that sphere of the Organization —

Eron Wahid: there’s a bit of role confusion right now because no one knows exactly what we’re here for. The staff looks at us like we’re a burden and giving them more work to do. They think we’re spies.

Panelist Nancy Hilton: @Katherine…the CNL will relieve the charge nurse for lunch, but does not assume the role

Peggy Austin: Does anyone utilize a CNL in the out pt surgery setting?

Tonya Cannon: to our VA facilities, would this person work in the NOD role?

Panelist Nancy Hilton: @Susan…the CNLs do not do direct care as an assignment, but definitely assist and step in when and where they are needed to support the staff nurse

Tami Swartz: Can we tag topics? Such as #salary or #designing model?

Peggy Austin: Susan do you or are you a CNL and what do you specifially do in surgical services?

Panelist Barbara Edwards: @Eron — We spent quite a bit of time discussing with staff, We worked with Charge Nurses, Staff Nurses and Case Managers to be sure that everyone understood roles and responsibilities.

Tim Rawson, ILN: good idea tami

Panelist Nancy Hilton: Regarding the Designing of the pilot units…we selected the units because they were the largest and needed the most support at the bedside

Panelist Barbara Edwards: @Tonya — What is NOD

Panelist Evelyn Rudd: @Tami it was a group collaboration for design model

Sandra Calm: @Myra Couch, I’m a CNL student from the University of Portland, working with Michele Goldschmidt here in the PVAMC ED. Feel free to contact me at calm09@up.edu.

Tim Rawson, ILN: What are the advantages/disadvantages of implementing this new care delivery model (by adding CNL’s)?

Peggy Austin: I currently work as a CNL over acute care services. This is a fairly new position and no defined role. The CNS rols hs been with the organization for years and is well defined.

Eron Wahid: how have you all been able to get the staff engaged?

Panelist Barbara Edwards: A CNL works with patient’s families, physicians and staff to ensure quality outcomes. There really is no time for additional responsibilities. We focus on Nurse sensitive quality indicators, patient satisfaction and physician satisfaction.

Eron Wahid: there is so much resistance from the staff as far as change

Panelist Nancy Hilton: @Kari we showed the model in one of the slides. the CNL works with about 3 primary nurses

Panelist Evelyn Rudd: @Tim disadvantages are the unknown, it relates to the a new position, “buy in” from all levels of organization, The Key is to have someone who believes in the role, our CNO

Panelist Barbara Edwards: @eron — WHY??? CNL’s supplement the care provided by the bedside nurse — They are there to support and supplement.

Panelist Nancy Hilton: we preapred the staff by having focus groups. both the charge nurses and the primary nurses had a difficult time as we started to discuss the role. it took about 3 months after implementation for everyone to understand the new design.

Panelist Gina Shouse: @Eron — when we implemented the role in the pilot units — we had a weekly conference with the staff re: concerns, issues or recommendations. We got their buy-in by asking for feedback and also including them in organizing the delivery care model

Peggy Austin: Susan we have nurses who call pts pre-op and tell them when to stop the Coumadin. Do you review all the pre-op assessments of your patients or how do you identify which ones have special needs? Could I get your email address?

Panelist Evelyn Rudd: @Peggy we do not currently have a CNL in that area

Eron Wahid: Nancy and Panelist, those are great ideas. im thinking me and the staff should have weekly meeting to discuss concerns

Kim Hall: Dramatic communication increase when the CNL implemented a morning and noon -huddle (situation awareness) where the staff briefly meet less than 5 minutes to discuss what our goals are for the day, anticipating resources we will need etc

Panelist Evelyn Rudd: @ Eron that sound like a wise choice, don’t give up, communication & support is the KEY

Glenda Webb: What capacity are CNL being used in Magnet hospitals?

Eron Wahid: So initially did you find that the staff was working with you or against you

Panelist Gina Shouse: Before implementing the role, we informed the staff of the CNL role, we had monthly conferences to educate the staff with concerns or questions they may have. We educated them re: bedside shift report, hourly rounding

Sandra Calm: Kim, what interventions were implemented to produce the 64% decrease in ED visits? What were your outcomes measures?

Panelist Gina Shouse: Our CHF re-admissions have decreased

Panelist Evelyn Rudd: @Eron at first I believe the was some resistance, when are became aware that nobody was going to take another position, it became a team effort

Peggy Barksdale: Across the country, CNL seem to have various roles — unit manager, quality personnel, a change agent, …facilities are noting the Master’s level & VA appears to be consistent in their CNL “tasks”

Panelist Nancy Hilton: Next Steps…to add another CNL to our Orthopedic Unit. We have one more CNL who will graduate in 2010. Then we will look at ED, ICU and OB

Myra Couch: What is the next step and how does the DNP level nurse fit into this if at all?

Peggy Austin: Nancy, How many beds do you have on your orthopedic unit and how many CNL’s

Barbara Edwards: @Eron — CNL’s made daily rounds and assisted nursing staff in obtaining specialty beds and wound care consults in a timely manner. The primary nurse may have every intention of requesting the same interventions — but it would be done after med passes, assessments ,breaks,… The CNL is able to get it down more timely.

Panelist Nancy Hilton: @Peggy…we have a census of 18-24 on our Ortho Unit..

Panelist Nancy Hilton: @Peggy…we will have 1 CNL

Panelist Barbara Edwards: It is nice to see that many of you are interested in the CNL role.

Peggy Barksdale: So, would certification say in Orthopaedics be a “plus” for the CNL?

Mary Robinson: Can anyone share documentation tools/requirements of a CNL. Any templates that would be beneficial?

Panelist Evelyn Rudd: @Participants, thank you for your time!

Nancy Hilton: I do believe the CNL is the role of the future for nursing. as a Nurse Exec i need to know we have clinical expertise at the bedside.

Barbara Edwards: @Mary — try looking at www.aacn.nche.edu\CNL.

Eron Wahid: oh i see Barbara. To anyone, what happens to those nurses who continue to chart in the same matter, fail to chart on wounds after management has been informed?

Kim Hall: To Nancy Hilton—Thank you for your support of the CNL role and enjoyed your presentation at the CNL Summit.

Peggy Austin: Very interesting topic with a great deal of helpful information. Would like to have had audio though:)

Panelist Nancy Hilton: @Kim…thank you very much.

Panelist Barbara Edwards: @eron — we coach and mentor, most of the time when nurses are resistant to change it is because they do not have the tools or know how to make the changes. I have not come across a situation where a nurse refused to comply. if it occurred I would defer to the unit manager

Host Judi Consalvo: I’m afraid we are now out of time and have to bring this Chat to a close. Sincere thanks to our presenters and our audience for a great exchange. We value your feedback. Please spend a few minutes to complete the evaluation that’s about to appear on your screen. You can also contact us at any time at info@innovations.ahrq.gov

eron wahid: thanks Barbara

Peggy Barksdale: It was 28 pages long this chat — thanks for the communication I see the CNL a little beter in their role.

June Estock: How does the CNL education differ from a Master Degree in Nursing? How does the education prepare them for the CNL role in comparison to a Masters in Nursing? Many Patient Care Facilitator roles mimic that of a CNL. Do you believe Masters prepared nurses can function in a similar role at the same level as a CNL prepared nurse?